Posted: Jan 14 2022 #(C101941)

Pulseless Supracondylar Humerus Fracture with Nerve Palsy in 5F

HPI

A 5-year-old female presented to the ED after falling on a trampoline. She has obvious deformity to her elbow with a pink, pulseless hand. She has numbness over the dorsal thumb and index finger and is unable to flex her thumb at the IP joint. She denies pain in her other extremities and did not hit her head during the accident.

PMH

She has no relevant medical history

Focused physical examination of the left elbow demonstrates obvious deformity with significant swelling and positive brachialis sign. She is unable to flex her thumb IP joint but other cardinal hand motions remain intact. She has decreased sensation over the dorsal thumb and index finger, otherwise sensation is intact. Radial pulse is not palpable or dopplerable but the hand remains perfused with capillary refill <2 seconds.

Poll

1 of 10

1. What additional imaging studies would you obtain?

None - current radiographs are sufficient

88%

1506/1694

Additional radiographic views

91/1694

Skeletal survey

21/1694

Additional radiographic views + skeletal survey

32/1694

Outside my area of expertise - best if I don't vote

44/1694

2. How would you classify this injury?

I would not use a classification system, it does not impact my management

153/1650

Gartland type II

11/1650

Gartland type III

31%

524/1650

Gartland type IV

51%

857/1650

Flexion type

20/1650

Outside my area of expertise - best if I don't vote

85/1650

3. How would you manage this injury?

Nonoperative (closed reduction, cast immobilization)

27/1665

Operative

97%

1625/1665

Outside my area of expertise - best if I don't vote

13/1665

4. If you choose Operative management and this patient presented in the evening, when would you perform surgery?

I would not choose Operative management

1/1676

Emergently (within hours)

71%

1204/1676

Urgently (same-day, I would not wait overnight)

22%

371/1676

Semi-urgently (next morning)

85/1676

Routine (follow-up in clinic to schedule surgery)

0/1676

Outside my area of expertise - best if I don't vote

15/1676

5. If you choose Operative management, what would be your plan going into surgery?

I would not choose Operative management

2/1667

Attempt Closed reduction percutaneous pinning (CRPP), convert to open only if needed

77%

1299/1667

Planned Open reduction percutaneous pinning (ORPP), don't attempt closed)

20%

337/1667

Outside my area of expertise - best if I don't vote

29/1667

6. If you choose Operative management, how would you manage the pink, pulseless hand?

I would not choose Operative management

4/1642

Only perform closed reduction and pinning

15%

249/1642

Attempt closed reduction and pinning, reassess pulse and if not present proceed to open

77%

1267/1642

Acute surgical exploration of brachial artery with open reduction

96/1642

Outside my area of expertise - best if I don't vote

26/1642

7. If you choose Operative management, how would you manage the AIN palsy?

I would not choose Operative management

40/1616

I would not address the AIN intraoperatively

81%

1323/1616

Acute surgical exploration with neurolysis

11%

193/1616

Outside my area of expertise - best if I don't vote

60/1616

8. If you choose Open reduction percutaneous pinning (ORPP), what approach would you use?

I would not choose ORPP

12%

189/1572

33%

530/1572

Lateral

28%

452/1572

Medial

135/1572

Posterior

11%

180/1572

Outside my area of expertise - best if I don't vote

86/1572

9. If you choose Closed reduction percutaneous pinning (CRPP) or Open reduction percutaneous pinning (ORPP), what fixation construct would you use?

I would not choose CRPP or ORPP

2/1524

Lateral only - 2 pins

10%

156/1524

Lateral only - 3 pins

22%

349/1524

Combined - 1 lateral and 1 medial pin

22%

342/1524

Combined - 2 lateral and 1 medial pin

36%

553/1524

Combined - 3 lateral and 1 medial pin

29/1524

Combined - 1 lateral and 2 medial pins

12/1524

Medial only - 2 pins

4/1524

Medial only - 3 pins

4/1524

Outside my area of expertise - best if I don't vote

73/1524

10. If you choose Operative management, how long would you observe this patient post-operatively?

I would not choose Operative management

3/1526

I would not observe the patient post-operatively

1/1526

Until AIN function recovered

122/1526

<12 hours, routinely

100/1526

12-24 hours, routinely

40%

617/1526

24-48 hours, routinely

33%

511/1526

48-72 hours, routinely

110/1526

>72 hours, routinely

29/1526

Outside my area of expertise - best if I don't vote

33/1526

PROCEDURE #2

Supracondylar Humerus Fx Closed Reduction and Percutaneous Pinning (CRPP). Patient was taken emergently to the operating room for CRPP (radial pulse returned after reduction). There was no concern for compartment syndrome at the time, but the patient was monitored the following day and released within 24 hours. The AIN palsy was not addressed intraoperatively but did completely resolve by 7-months postoperatively.

Intra-procedure P2

Post-procedure P2

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